Book: The Post-Traumatic Stress Disorder Sourcebook

Book Title:

The Post-Traumatic Stress Disorder Sourcebook, Revised and Expanded Second Edition: A Guide to Healing, Recovery, and Growth.

Author(s): Glenn R. Schiraldi (PhD).

Year: 2016.

Edition: Second (2nd).

Publisher: McGraw-Hill Education.

Type(s): Paperback and Kindle.

Synopsis:

The Post-Traumatic Stress Disorder Sourcebook, Revised and Expanded Second Edition introduces survivors, loved ones, and helpers to the remarkable range of treatment alternatives and self-management techniques available today to break through the pain and realise recovery and growth.

This updated edition incorporates all-new diagnostics from the DSM-5 and covers the latest treatment techniques and research findings surrounding the optimisation of brain health and function, sleep disturbance, new USDA dietary guidelines and the importance of antioxidants, early childhood trauma, treating PTSD and alcoholism, the relationship between PTSD and brain injury, suicide and PTSD, somatic complaints associated with PTSD, and more.

What is Early Intervention in Psychosis?

Introduction

Early intervention in psychosis is a clinical approach to those experiencing symptoms of psychosis for the first time. It forms part of a new prevention paradigm for psychiatry and is leading to reform of mental health services, especially in the United Kingdom and Australia.

This approach centres on the early detection and treatment of early symptoms of psychosis during the formative years of the psychotic condition. The first three to five years are believed by some to be a critical period. The aim is to reduce the usual delays to treatment for those in their first episode of psychosis. The provision of optimal treatments in these early years is thought to prevent relapses and reduce the long-term impact of the condition. It is considered a secondary prevention strategy.

The duration of untreated psychosis (DUP) has been shown as an indicator of prognosis, with a longer DUP associated with more long-term disability.

Components of the Model

There are a number of functional components of the early psychosis model, and they can be structured as different sub-teams within early psychosis services. The emerging pattern of sub-teams are currently:

  • Early psychosis treatment teams;
  • Early detection function; and
  • Prodrome clinics.

Early Psychosis Treatment Teams

Multidisciplinary clinical teams providing an intensive case management approach for the first three to five years. The approach is similar to assertive community treatment, but with an increased focus on the engagement and treatment of this previously untreated population and the provision of evidence based, optimal interventions for clients in their first episode of psychosis. For example, the use of low-dose antipsychotic medication is promoted (“start low, go slow”), with a need for monitoring of side effects and an intensive and deliberate period of psycho-education for patients and families that are new to the mental health system. In addition, researchers in Spain showed that family intervention for psychosis (FIP) reduced relapse rates, hospitalization duration, and psychotic symptoms along with increasing functionality in first-episode psychosis (FEP) up to 24 months, according to a recent review published in Schizophrenia Bulletin. Interventions to prevent a further episodes of psychosis (a “relapse”) and strategies that encourage a return to normal vocation and social activity are a priority. There is a concept of phase specific treatment for acute, early recovery and late recovery periods in the first episode of psychosis.

Early Detection Function

Interventions aimed at avoiding late detection and engagement of those in the course of their psychotic conditions. Key tasks include being aware of early signs of psychosis and improving pathways into treatment. Teams provide information and education to the general public and assist GPs with recognition and response to those with suspected signs, for example:

  • EPPIC’s Youth Access Team (YAT) (Melbourne, Australia);
  • OPUS (Denmark);
  • TIPS (Norway);
  • REDIRECT (Birmingham, UK);
  • LEO CAT (London, UK); and
  • STEP’s Population Health approach to early detection.

The development and implementation of quantitative tools for early detection of at-risk individuals is an active research area. This includes development of risk calculators and methods for large-scale population screening.

Prodrome Clinics

Prodrome or at risk mental state clinics are specialist services for those with subclinical symptoms of psychosis or other indicators of risk of transition to psychosis. The Pace Clinic in Melbourne, Australia, is considered one of the origins of this strategy, but a number of other services and research centres have since developed. These services are able to reliably identify those at high risk of developing psychosis and are beginning to publish encouraging outcomes from randomised controlled trials that reduce the chances of becoming psychotic, including evidence that psychological therapy and high doses of fish oil have a role in the prevention of psychosis. However, a meta-analysis of five trials found that while these interventions reduced risk of psychosis after 1 year (11% conversion to psychosis in intervention groups compared to 32% in control groups), these gains were not maintained over 2-3 years of follow-up. These findings indicate that interventions delay psychosis, but do not reduce the long-term risk. There has also been debate about the ethics of using antipsychotic medication to reduce the risk of developing psychosis, because of the potential harms involved with these medications.

In 2015, the European Psychiatric Association issued guidance recommending the use of the Cognitive Disturbances scale (COGDIS), a subscale of the basic symptoms scale, to assess psychosis risk; a meta-analysis conducted for the guidance found that while rates of conversion to psychosis were similar to those who meet Ultra High Risk (UHR) criteria up to 2 years after assessment, they were significantly higher after 2 years for those patients who met the COGDIS criteria. The COGDIS criteria measure subjective symptoms, and include such symptoms as thought interference, where irrelevant and emotionally unimportant thought contents interfere with the main line of thinking; thought block, where the current train of thought halts; thought pressure, where thoughts unrelated to a common topic appear uncontrollably; referential ideation that is immediately corrected; and other characteristic disturbances of attention and the use or understanding of language.

Brief History

Early intervention in psychosis is a preventive approach for psychosis that has evolved as contemporary recovery views of psychosis and schizophrenia have gained acceptance. It subscribes to a “post Kraepelin” concept of schizophrenia, challenging the assumptions originally promoted by Emil Kraepelin in the 19th century, that schizophrenia (“dementia praecox”) was a condition with a progressing and deteriorating course. The work of Post, whose kindling model, together with Fava and Kellner, who first adapted staging models to mental health, provided an intellectual foundation. Psychosis is now formulated within a diathesis-stress model, allowing a more hopeful view of prognosis, and expects full recovery for those with early emerging psychotic symptoms. It is more aligned with psychosis as continuum (such as with the concept of schizotypy) with multiple contributing factors, rather than schizophrenia as simply a neurobiological disease.

Within this changing view of psychosis and schizophrenia, the model has developed from a divergence of several different ideas, and from a number of sites, beginning with the closure of psychiatric institutions signalling a move toward community based care. In 1986, the Northwick Park study discovered an association between delays to treatment and disability, questioning the service provision for those with their first episode of schizophrenia. In the 1990s, evidence began to emerge that cognitive behavioural therapy was an effective treatment for delusions and hallucinations. The next step came with the development of the EPPIC early detection service in Melbourne, Australia in 1996 and the prodrome clinic led by Alison Yung. This service was an inspiration to other services, such as the West Midlands IRIS group, including the carer charity Rethink Mental Illness; the TIPS early detection randomised control trial in Norway; and the Danish OPUS trial. In 2001, the United Kingdom Department of Health called the development of early psychosis teams “a priority”. The International Early Psychosis Association, founded in 1998, issued an international consensus declaration together with the World Health Organisation in 2004. Clinical practice guidelines have been written by consensus.

Clinical Outcome Evidence

A number of studies have been carried out to see whether the early psychosis approach reduces the severity of symptoms, improves relapse rates, and decreases the use of inpatient care, in comparison to standard care. Advocates of early intervention for psychosis have been accused of selectively citing findings that support the benefits of early intervention, but ignoring findings that do not. It has been argued that the scientific reporting of evidence on early intervention in psychosis is characterised by a high prevalence of ‘spin’ and ‘bias’. An analysis of the summaries of articles found that 75% implied positive results, whereas examination of the findings with primary measures from these studies found that only 13% were positive.

Evidence on Cost

Studies have been published claiming that early psychosis services cost less than standard services, largely through reduced in-patient costs, and also save other costs to society. However, the claimed savings have been disputed. A 2012 systematic review of the evidence concluded that: “The published literature does not support the contention that early intervention for psychosis reduces costs or achieves cost-effectiveness”.

Reform of Mental Health Services

United Kingdom

The United Kingdom has made significant service reform with their adoption of early psychosis teams following the first service in Birmingham set up by Professor Max Birchwood in 1994 and used as a blueprint for national roll-out, with early psychosis now considered as an integral part of comprehensive community mental health services. The Mental Health Policy Implementation Guide outlines service specifications and forms the basis of a newly developed fidelity tool. There is a requirement for services to reduce the duration of untreated psychosis, as this has been shown to be associated with better long-term outcomes. The implementation guideline recommends:

  • 14 to 35 year age entry criteria.
  • First three years of psychotic illness.
  • Aim to reduce the duration of untreated psychosis to less than 3 months.
  • Maximum caseload ratio of 1 care coordinator to 10-15 clients.
  • For every 250,000 (depending on population characteristics), one team:
    • Total caseload 120 to 150.
    • 1.5 doctors per team.
    • Other specialist staff to provide specific evidence based interventions.

Australia and New Zealand

In Australia the EPPIC initiative provides early intervention services. In the Australian government’s 2011 budget, $222.4 million was provided to fund 12 new EPPIC centres in collaboration with the states and territories. However, there have been criticisms of the evidence base for this expansion and of the claimed cost savings.

On 19 August 2011, Patrick McGorry, South Australian Social Inclusion Commissioner David Cappo AO and Frank Quinlan, CEO of the Mental Health Council of Australia, addressed a meeting of the Council of Australian Governments (COAG), chaired by Prime Minister Julia Gillard, on the future direction of mental health policy and the need for priority funding for early intervention. The invitation, an initiative of South Australian Premier Mike Rann, followed the release of Cappo’s “Stepping Up” report, supported by the Rann Government, which recommended a major overhaul of mental health in South Australia, including stepped levels of care and early intervention.

New Zealand has operated significant early psychosis teams for more than 20 years, following the inclusion of early psychosis in a mental health policy document in 1997. There is a national early psychosis professional group, New Zealand Early Intervention for Psychosis Society (NZEIPS), organising a biannual training event, advocating for evidenced based service reform and supporting production of local resources.

Scandinavia

Early psychosis programmes have continued to develop from the original TIPS services in Norway and the OPUS randomised trial in Denmark.

North America

Canada has extensive coverage across most provinces, including established clinical services and comprehensive academic research in British Columbia (Vancouver), Alberta (EPT in Calgary), Quebec (PEPP-Montreal), and Ontario (PEPP, FEPP).

In the United States, the Early Assessment Support Alliance (EASA) is implementing early psychosis intervention throughout the state of Oregon.

In the United States, the implementation of Coordinated Specialty Care (CSC), as a recovery-oriented treatment program for people with first episode psychosis (FEP), has become a US health policy priority. CSC promotes shared decision making and uses a team of specialists who work with the client to create a personal treatment plan. The specialists offer psychotherapy, medication management geared to individuals with FEP, family education and support, case management, and work or education support, depending on the individual’s needs and preferences. The client and the team work together to make treatment decisions, involving family members as much as possible. The goal is to link the individual with a CSC team as soon as possible after psychotic symptoms begin because a longer period of unchecked and untreated illness might be associated with poorer outcomes.

Asia

The first meeting of the Asian Network of Early Psychosis (ANEP) was held in 2004. There are now established services in Singapore, Hong Kong and South Korea.

What is Anti-Psychiatry?

Introduction

Anti-psychiatry is a movement based on the view that psychiatric treatment is more often damaging than helpful to patients. It considers psychiatry a coercive instrument of oppression due to an unequal power relationship between doctor and patient, and a highly subjective diagnostic process. Wrongful involuntary commitment is an important issue in the movement. It has been active in various forms for two centuries. Anti-psychiatry originates in an objection to what some view as dangerous treatments.

In the 1960s, there were many challenges to psychoanalysis and mainstream psychiatry, where the very basis of psychiatric practice was characterised as repressive and controlling. Psychiatrists involved in this challenge included Thomas Szasz, Giorgio Antonucci, R. D. Laing, Franco Basaglia, Theodore Lidz, Silvano Arieti, and David Cooper. Others involved were L. Ron Hubbard (science fiction author & founder of scientology), Michel Foucault, Gilles Deleuze, Félix Guattari, and Erving Goffman. Cooper coined the term “anti-psychiatry” in 1967, and wrote the book Psychiatry and Anti-psychiatry in 1971. Thomas Szasz introduced the definition of mental illness as a myth in the book The Myth of Mental Illness (1961), Giorgio Antonucci introduced the definition of psychiatry as a prejudice in the book I pregiudizi e la conoscenza critica alla psichiatria (1986).

Contemporary issues of anti-psychiatry include freedom versus coercion, racial and social justice, effects of antipsychotic medications, mental illness unintentionally induced by medical therapy, personal liberty, social stigma, and the right to be different.

Examples of historically dangerous treatments include electroconvulsive therapy, insulin shock therapy, and brain lobotomy. A more recent concern is the significant increase in prescribing psychiatric drugs for children in the beginning of the 21st century. There were also concerns about mental health institutions. All modern societies permit involuntary treatment or involuntary commitment of mental patients.

Brief History

Precursors

The first widespread challenge to the prevailing medical approach in Western countries occurred in the late 18th century. Part of the progressive Age of Enlightenment, a “moral treatment” movement challenged the harsh, pessimistic, somatic (body-based) and restraint-based approaches that prevailed in the system of hospitals and “madhouses” for people considered mentally disturbed, who were generally seen as wild animals without reason. Alternatives were developed, led in different regions by ex-patient staff, physicians themselves in some cases, and religious and lay philanthropists. The moral treatment was seen as pioneering more humane psychological and social approaches, whether or not in medical settings; however, it also involved some use of physical restraints, threats of punishment, and personal and social methods of control. And as it became the establishment approach in the 19th century, opposition to its negative aspects also grew.

According to Michel Foucault, there was a shift in the perception of madness, whereby it came to be seen as less about delusion, i.e. disturbed judgment about the truth, than about a disorder of regular, normal behaviour or will. Foucault argued that, prior to this, doctors could often prescribe travel, rest, walking, retirement and generally engaging with nature, seen as the visible form of truth, as a means to break with artificialities of the world (and therefore delusions). Another form of treatment involved nature’s opposite, the theatre, where the patient’s madness was acted out for him or her in such a way that the delusion would reveal itself to the patient.

According to Foucault, the most prominent therapeutic technique instead became to confront patients with a healthy sound will and orthodox passions, ideally embodied by the physician. The cure then involved a process of opposition, of struggle and domination, of the patient’s troubled will by the healthy will of the physician. It was thought the confrontation would lead not only to bring the illness into broad daylight by its resistance, but also to the victory of the sound will and the renunciation of the disturbed will. We must apply a perturbing method, to break the spasm by means of the spasm…. We must subjugate the whole character of some patients, subdue their transports, break their pride, while we must stimulate and encourage the others (Esquirol, J.E.D., 1816). Foucault also argued that the increasing internment of the “mentally ill” (the development of more and bigger asylums) had become necessary not just for diagnosis and classification but because an enclosed place became a requirement for a treatment that was now understood as primarily the contest of wills, a question of submission and victory.

The techniques and procedures of the asylums at this time included “isolation, private or public interrogations, punishment techniques such as cold showers, moral talks (encouragements or reprimands), strict discipline, compulsory work, rewards, preferential relations between the physician and his patients, relations of vassalage, of possession, of domesticity, even of servitude between patient and physician at times”. Foucault summarised these as “designed to make the medical personage the ‘master of madness'” through the power the physician’s will exerts on the patient. The effect of this shift then served to inflate the power of the physician relative to the patient, correlated with the rapid rise of internment (asylums and forced detention).

Other analyses suggest that the rise of asylums was primarily driven by industrialization and capitalism, including the breakdown of the traditional family structures. And that by the end of the 19th century, psychiatrists often had little power in the overrun asylum system, acting mainly as administrators who rarely attended to patients, in a system where therapeutic ideals had turned into mindless institutional routines. In general, critics point to negative aspects of the shift toward so-called “moral treatments”, and the concurrent widespread expansion of asylums, medical power and involuntary hospitalisation laws, in a way that was to play an important conceptual part in the later anti-psychiatry movement.

Various 19th-century critiques of the newly emerging field of psychiatry overlap thematically with 20th-century anti-psychiatry, for example in their questioning of the medicalisation of “madness”. Those critiques occurred at a time when physicians had not yet achieved hegemony through psychiatry, however, so there was no single, unified force to oppose. Nevertheless, there was increasing concern at the ease with which people could be confined, with frequent reports of abuse and illegal confinement. For example, Daniel Defoe, the author of Robinson Crusoe, had previously argued for more government oversight of “madhouses” and for due process prior to involuntary internment. He later argued that husbands used asylum hospitals to incarcerate their disobedient wives, and in a subsequent pamphlet that wives even did the same to their husbands. It was also proposed that the role of asylum keeper be separated from doctor, to discourage exploitation of patients. There was general concern that physicians were undermining personhood by medicalising problems, by claiming they alone had the expertise to judge it, and by arguing that mental disorder was physical and hereditary. The Alleged Lunatics’ Friend Society arose in England in the mid-19th century to challenge the system and campaign for rights and reforms. In the United States, Elizabeth Packard published a series of books and pamphlets describing her experiences in the Illinois insane asylum, to which she had been committed at the request of her husband.

Throughout, the class nature of mental hospitals, and their role as agencies of control, were well recognised. And the new psychiatry was partially challenged by two powerful social institutions – the church and the legal system. These trends have been thematically linked to the later 20th century anti-psychiatry movement.

As psychiatry became more professionally established during the nineteenth century (the term itself was coined in 1808 in Germany, as “Psychiatriein”) and developed allegedly more invasive treatments, opposition increased. In the Southern US, black slaves and abolitionists encountered Drapetomania, a pseudo-scientific diagnosis for why slaves ran away from their masters.

There was some organised challenge to psychiatry in the late 1870s from the new speciality of neurology. Practitioners criticised mental hospitals for failure to conduct scientific research and adopt the modern therapeutic methods such as nonrestraint. Together with lay reformers and social workers, neurologists formed the National Association for the Protection of the Insane and the Prevention of Insanity. However, when the lay members questioned the competence of asylum physicians to even provide proper care at all, the neurologists withdrew their support and the association floundered.

Early 1900s

It has been noted that “the most persistent critics of psychiatry have always been former mental hospital patients”, but that very few were able to tell their stories publicly or to confront the psychiatric establishment openly, and those who did so were commonly considered so extreme in their charges that they could seldom gain credibility. In the early 20th century, ex-patient Clifford W. Beers campaigned to improve the plight of individuals receiving public psychiatric care, particularly those committed to state institutions, publicizing the issues in his book, A Mind that Found Itself (1908). While Beers initially condemned psychiatrists for tolerating mistreatment of patients, and envisioned more ex-patient involvement in the movement, he was influenced by Adolf Meyer and the psychiatric establishment, and toned down his hostility since he needed their support for reforms. In Germany there were similar movements which used the term “Antipsychiatrie”.

His reliance on rich donors and his need for approval from experts led him to hand over to psychiatrists the organisation he helped found, the National Committee for Mental Hygiene which eventually became the National Mental Health Association. In the UK, the National Society for Lunacy Law Reform was established in 1920 by angry ex-patients who sought justice for abuses committed in psychiatric custody, and were aggrieved that their complaints were patronisingly discounted by the authorities, who were seen to value the availability of medicalised internment as a ‘whitewashed’ extrajudicial custodial and punitive process. In 1922, ex-patient Rachel Grant-Smith added to calls for reform of the system of neglect and abuse she had suffered by publishing “The Experiences of an Asylum Patient”. In the US, We Are Not Alone (WANA) was founded by a group of patients at Rockland State Hospital in New York, and continued to meet as an ex-patient group.

In the 1920s, extreme hostility to psychiatrists and psychiatry was expressed by the French playwright and theatre director Antonin Artaud, in particular, in his book on van Gogh. To Artaud, imagination was reality. Much influenced by the Dada and surrealist enthusiasms of the day, he considered dreams, thoughts and visions no less real than the “outside” world. To Artaud, reality appeared little more than a convenient consensus, the same kind of consensus an audience accepts when they enter a theatre and, for a time, are happy to pretend what they are seeing is real.

In this era before penicillin was discovered, eugenics was popular. People believed diseases of the mind could be passed on so compulsory sterilisation of the mentally ill was enacted in many countries.

Early 1930s

In the 1930s several controversial medical practices were introduced, including inducing seizures (by electroshock, insulin or other drugs) or cutting parts of the brain apart (lobotomy). In the US, between 1939 and 1951, over 50,000 lobotomy operations were performed in mental hospitals. But lobotomy was ultimately seen as too invasive and brutal.

Holocaust historians argued that the medicalisation of social programmes and systematic euthanasia of people in German mental institutions in the 1930s provided the institutional, procedural, and doctrinal origins of the mass murder of the 1940s. The Nazi programmes were called Action T4 and Action 14f13. The Nuremberg Trials convicted a number of psychiatrists who held key positions in Nazi regimes. For instance this idea of a Swiss psychiatrist: “A not so easy question to be answered is whether it should be allowed to destroy lives objectively ‘unworthy of living’ without the expressed request of its bearers. (…) Even in incurable mentally ill ones suffering seriously from hallucinations and melancholic depressions and not being able to act, to a medical colleague I would ascript the right and in serious cases the duty to shorten – often for many years – the suffering” (Bleuler, Eugen, 1936: “Die naturwissenschaftliche Grundlage der Ethik”. Schweizer Archiv Neurologie und Psychiatrie, Band 38, Nr.2, S. 206).

1940s and 1950s

The post-World War II decades saw an enormous growth in psychiatry; many Americans were persuaded that psychiatry and psychology, particularly psychoanalysis, were a key to happiness. Meanwhile, most hospitalised mental patients received at best decent custodial care, and at worst, abuse and neglect.

The psychoanalyst Jacques Lacan has been identified as an influence on later anti-psychiatry theory in the UK, and as being the first, in the 1940s and 50s, to professionally challenge psychoanalysis to re-examine its concepts and to appreciate psychosis as understandable. Other influences on Lacan included poetry and the surrealist movement, including the poetic power of patients’ experiences. Critics disputed this and questioned how his descriptions linked to his practical work. The names that came to be associated with the anti-psychiatry movement knew of Lacan and acknowledged his contribution even if they did not entirely agree. The psychoanalyst Erich Fromm is also said to have articulated, in the 1950s, the secular humanistic concern of the coming anti-psychiatry movement. In The Sane Society (1955), Fromm wrote “”An unhealthy society is one which creates mutual hostility [and] distrust, which transforms man into an instrument of use and exploitation for others, which deprives him of a sense of self, except inasmuch as he submits to others or becomes an automaton”…”Yet many psychiatrists and psychologists refuse to entertain the idea that society as a whole may be lacking in sanity. They hold that the problem of mental health in a society is only that of the number of ‘unadjusted’ individuals, and not of a possible unadjustment of the culture itself”.

In the 1950s, new psychiatric drugs, notably the antipsychotic chlorpromazine, slowly came into use. Although often accepted as an advance in some ways, there was opposition, partly due to serious adverse effects such as tardive dyskinesia, and partly due their “chemical straitjacket” effect and their alleged use to control and intimidate patients. Patients often opposed psychiatry and refused or stopped taking the drugs when not subject to psychiatric control. There was also increasing opposition to the large-scale use of psychiatric hospitals and institutions, and attempts were made to develop services in the community.

In the 1950s in the United States, a right-wing anti-mental health movement opposed psychiatry, seeing it as liberal, left-wing, subversive and anti-American or pro-Communist. There were widespread fears that it threatened individual rights and undermined moral responsibility. An early skirmish was over the Alaska Mental Health Bill, where the right wing protestors were joined by the emerging Scientology movement.

The field of psychology sometimes came into opposition with psychiatry. Behaviourists argued that mental disorder was a matter of learning not medicine; for example, Hans Eysenck argued that psychiatry “really has no role to play”. The developing field of clinical psychology in particular came into close contact with psychiatry, often in opposition to its methods, theories and territories.

1960s

Coming to the fore in the 1960s, “anti-psychiatry” (a term first used by David Cooper in 1967) defined a movement that vocally challenged the fundamental claims and practices of mainstream psychiatry. While most of its elements had precedents in earlier decades and centuries, in the 1960s it took on a national and international character, with access to the mass media and incorporating a wide mixture of grassroots activist organisations and prestigious professional bodies.

Cooper was a South African psychiatrist working in Britain. A trained Marxist revolutionary, he argued that the political context of psychiatry and its patients had to be highlighted and radically challenged, and warned that the fog of individualised therapeutic language could take away people’s ability to see and challenge the bigger social picture. He spoke of having a goal of “non-psychiatry” as well as anti-psychiatry.

“In the 1960s fresh voices mounted a new challenge to the pretensions of psychiatry as a science and the mental health system as a successful humanitarian enterprise. These voices included: Ernest Becker, Erving Goffman, R.D. Laing; Laing and Aaron Esterson, Thomas Scheff, and Thomas Szasz. Their writings, along with others such as articles in the journal The Radical Therapist, were given the umbrella label “antipsychiatry” despite wide divergences in philosophy. This critical literature, in concert with an activist movement, emphasized the hegemony of medical model psychiatry, its spurious sources of authority, its mystification of human problems, and the more oppressive practices of the mental health system, such as involuntary hospitalisation, drugging, and electroshock”.
The psychiatrists R D Laing (from Scotland), Theodore Lidz (from America), Silvano Arieti (from Italy) and others, argued that “schizophrenia” and psychosis were understandable, and resulted from injuries to the inner self-inflicted by psychologically invasive “schizophrenogenic” parents or others. It was sometimes seen as a transformative state involving an attempt to cope with a sick society. Laing, however, partially dissociated himself from his colleague Cooper’s term “anti-psychiatry”. Laing had already become a media icon through bestselling books (such as The Divided Self and The Politics of Experience) discussing mental distress in an interpersonal existential context; Laing was somewhat less focused than his colleague Cooper on wider social structures and radical left wing politics, and went on to develop more romanticised or mystical views (as well as equivocating over the use of diagnosis, drugs and commitment). Although the movement originally described as anti-psychiatry became associated with the general counter-culture movement of the 1960s, Lidz and Arieti never became involved in the latter. Franco Basaglia promoted anti-psychiatry in Italy and secured reforms to mental health law there.

Laing, through the Philadelphia Association founded with Cooper in 1965, set up over 20 therapeutic communities including Kingsley Hall, where staff and residents theoretically assumed equal status and any medication used was voluntary. Non-psychiatric Soteria houses, starting in the United States, were also developed as were various ex-patient-led services.

Psychiatrist Thomas Szasz argued that “mental illness” is an inherently incoherent combination of a medical and a psychological concept. He opposed the use of psychiatry to forcibly detain, treat, or excuse what he saw as mere deviance from societal norms or moral conduct. As a libertarian, Szasz was concerned that such usage undermined personal rights and moral responsibility. Adherents of his views referred to “the myth of mental illness”, after Szasz’s controversial 1961 book of that name (based on a paper of the same name that Szasz had written in 1957 that, following repeated rejections from psychiatric journals, had been published in the American Psychologist in 1960). Although widely described as part of the main anti-psychiatry movement, Szasz actively rejected the term and its adherents; instead, in 1969, he collaborated with Scientology to form the Citizens Commission on Human Rights. It was later noted that the view that insanity was not in most or even in any instances a “medical” entity, but a moral issue, was also held by Christian Scientists and certain Protestant fundamentalists, as well as Szasz. Szasz was not a Scientologist himself and was non-religious; he commented frequently on the parallels between religion and psychiatry.

Erving Goffman, Gilles Deleuze, Félix Guattari and others criticised the power and role of psychiatry in society, including the use of “total institutions” and the use of models and terms that were seen as stigmatizing. The French sociologist and philosopher Foucault, in his 1961 publication Madness and Civilization: A History of Insanity in the Age of Reason, analysed how attitudes towards those deemed “insane” had changed as a result of changes in social values. He argued that psychiatry was primarily a tool of social control, based historically on a “great confinement” of the insane and physical punishment and chains, later exchanged in the moral treatment era for psychological oppression and internalized restraint. American sociologist Thomas Scheff applied labelling theory to psychiatry in 1966 in “Being Mentally Ill”. Scheff argued that society views certain actions as deviant and, in order to come to terms with and understand these actions, often places the label of mental illness on those who exhibit them. Certain expectations are then placed on these individuals and, over time, they unconsciously change their behaviour to fulfil them.

Observation of the abuses of psychiatry in the Soviet Union in the so-called Psikhushka hospitals also led to questioning the validity of the practice of psychiatry in the West. In particular, the diagnosis of many political dissidents with schizophrenia led some to question the general diagnosis and punitive usage of the label schizophrenia. This raised questions as to whether the schizophrenia label and resulting involuntary psychiatric treatment could not have been similarly used in the West to subdue rebellious young people during family conflicts.

Since 1970

New professional approaches were developed as an alternative or reformist complement to psychiatry. The Radical Therapist, a journal begun in 1971 in North Dakota by Michael Glenn, David Bryan, Linda Bryan, Michael Galan and Sara Glenn, challenged the psychotherapy establishment in a number of ways, raising the slogan “Therapy means change, not adjustment.” It contained articles that challenged the professional mediator approach, advocating instead revolutionary politics and authentic community making. Social work, humanistic or existentialist therapies, family therapy, counselling and self-help and clinical psychology developed and sometimes opposed psychiatry.

Psychoanalysis was increasingly criticised as unscientific or harmful. Contrary to the popular view, critics and biographers of Freud, such as Alice Miller, Jeffrey Masson and Louis Breger, argued that Freud did not grasp the nature of psychological trauma. Non-medical collaborative services were developed, for example therapeutic communities or Soteria houses.

The psychoanalytically trained psychiatrist Szasz, although professing fundamental opposition to what he perceives as medicalisation and oppressive or excuse-giving “diagnosis” and forced “treatment”, was not opposed to other aspects of psychiatry (for example attempts to “cure-heal souls”, although he also characterises this as non-medical). Although generally considered anti-psychiatry by others, he sought to dissociate himself politically from a movement and term associated with the radical left-wing. In a 1976 publication “Anti-psychiatry: The paradigm of a plundered mind”, which has been described as an overtly political condemnation of a wide sweep of people, Szasz claimed Laing, Cooper and all of anti-psychiatry consisted of “self-declared socialists, communists, anarchists or at least anti-capitalists and collectivists”. While saying he shared some of their critique of the psychiatric system, Szasz compared their views on the social causes of distress/deviance to those of anti-capitalist anti-colonialists who claimed that Chilean poverty was due to plundering by American companies, a comment Szasz made not long after a CIA-backed coup had deposed the democratically elected Chilean president and replaced him with Pinochet. Szasz argued instead that distress/deviance is due to the flaws or failures of individuals in their struggles in life.

The anti-psychiatry movement was also being driven by individuals with adverse experiences of psychiatric services. This included those who felt they had been harmed by psychiatry or who felt that they could have been helped more by other approaches, including those compulsorily (including via physical force) admitted to psychiatric institutions and subjected to compulsory medication or procedures. During the 1970s, the anti-psychiatry movement was involved in promoting restraint from many practices seen as psychiatric abuses.

The gay rights movement continued to challenge the classification of homosexuality as a mental illness and in 1974, in a climate of controversy and activism, the American Psychiatric Association membership (following a unanimous vote by the trustees in 1973) voted by a small majority (58%) to remove it as an illness category from the DSM, replacing it with a category of “sexual orientation disturbance” and then “ego-dystonic homosexuality,” which was deleted in 1986, although a wide variety of “paraphilias” remain. The diagnostic label gender identity disorder (GID) was used by the DSM until its reclassification as gender dysphoria in 2013, with the release of the DSM-5. The diagnosis was reclassified to better align it with medical understanding of the condition and to remove the stigma associated with the term disorder. The American Psychiatric Association, publisher of the DSM-5, stated that gender nonconformity is not the same thing as gender dysphoria, and that “gender nonconformity is not in itself a mental disorder. The critical element of gender dysphoria is the presence of clinically significant distress associated with the condition.” Some transgender people and researchers support declassification of the condition because they say the diagnosis pathologizes gender variance and reinforces the binary model of gender. It has been noted that gay activists in the 1970s and 1980s adopted many of Szasz’s arguments against the psychiatric system, but also that Szasz had written in 1965 that: “I believe it is very likely that homosexuality is, indeed, a disease in the second sense [expression of psychosexual immaturity] and perhaps sometimes even in the stricter sense [a condition somewhat similar to ordinary organic maladies perhaps caused by genetic error or endocrine imbalance]. Nevertheless, if we believe that by categorising homosexuality as a disease we have succeeded in removing it from the realm of moral judgement, we are in error.”

Increased legal and professional protections, and a merging with human rights and disability rights movements, added to anti-psychiatry theory and action.

Anti-psychiatry came to challenge a “biomedical” focus of psychiatry (defined to mean genetics, neurochemicals and pharmaceutic drugs). There was also opposition to the increasing links between psychiatry and pharmaceutical companies, which were becoming more powerful and were increasingly claimed to have excessive, unjustified and underhand influence on psychiatric research and practice. There was also opposition to the codification of, and alleged misuse of, psychiatric diagnoses into manuals, in particular the American Psychiatric Association, which publishes the Diagnostic and Statistical Manual of Mental Disorders.

Anti-psychiatry increasingly challenged alleged psychiatric pessimism and institutionalised alienation regarding those categorised as mentally ill. An emerging consumer/survivor movement often argues for full recovery, empowerment, self-management and even full liberation. Schemes were developed to challenge stigma and discrimination, often based on a social model of disability; to assist or encourage people with mental health issues to engage more fully in work and society (for example through social firms), and to involve service users in the delivery and evaluation of mental health services. However, those actively and openly challenging the fundamental ethics and efficacy of mainstream psychiatric practice remained marginalised within psychiatry, and to a lesser extent within the wider mental health community.

Three authors came to personify the movement against psychiatry, and two of these were practising psychiatrists. The initial and most influential of these was Thomas Szasz who rose to fame with his book The Myth of Mental Illness, although Szasz himself did not identify as an anti-psychiatrist. The well-respected R.D. Laing wrote a series of best-selling books, including The Divided Self. Intellectual philosopher Michel Foucault challenged the very basis of psychiatric practice and cast it as repressive and controlling. The term “anti-psychiatry” was coined by David Cooper in 1967. In parallel with the theoretical production of the mentioned authors, the Italian physician Giorgio Antonucci questioned the basis themselves of psychiatry through the dismantling of the psychiatric hospitals Osservanza and Luigi Lolli and the liberation – and restitution to life – of the people there secluded.

Challenges to Psychiatry

Civilisation as a Cause of Distress

In recent years, psychotherapists David Smail and Bruce E. Levine, considered part of the anti-psychiatry movement, have written widely on how society, culture, politics and psychology intersect. They have written extensively of the “embodied nature” of the individual in society, and the unwillingness of even therapists to acknowledge the obvious part played by power and financial interest in modern Western society. They argue that feelings and emotions are not, as is commonly supposed, features of the individual, but rather responses of the individual to their situation in society. Even psychotherapy, they suggest, can only change feelings in as much as it helps a person to change the “proximal” and “distal” influences on their life, which range from family and friends, to the workplace, socio-economics, politics and culture.

R.D. Laing emphasized family nexus as a mechanism by which individuals become victimized by those around them, and spoke about a dysfunctional society.

Inadequacy of Clinical Interviews Used to Diagnose ‘Diseases’

An aetiology common to bipolar spectrum disorders has not been identified. Patients cannot be identified just by clinical interviews. A neurobiological basis of bipolar disorder has not been discovered. In making a bipolar spectrum disorder diagnosis based solely on a clinical interview, a false positive cannot be avoided.

Psychiatrists have been trying to differentiate mental disorders based on clinical interviews since the era of Kraepelin, but now realise that their diagnostic criteria are imperfect. Tadafumi Kato writes, “We psychiatrists should be aware that we cannot identify ‘diseases’ only by interviews. What we are doing now is just like trying to diagnose diabetes mellitus without measuring blood sugar.”

Normality and Illness Judgements

In 2013, psychiatrist Allen Frances said that “psychiatric diagnosis still relies exclusively on fallible subjective judgments rather than objective biological tests”.

Reasons have been put forward to doubt the ontic status of mental disorders. Mental disorders engender ontological scepticism on three levels:

  • Mental disorders are abstract entities that cannot be directly appreciated with the human senses or indirectly, as one might with macro- or microscopic objects.
  • Mental disorders are not clearly natural processes whose detection is untarnished by the imposition of values, or human interpretation.
  • It is unclear whether they should be conceived as abstractions that exist in the world apart from the individual persons who experience them, and thus instantiate them.

In the scientific and academic literature on the definition or classification of mental disorder, one extreme argues that it is entirely a matter of value judgements (including of what is normal) while another proposes that it is or could be entirely objective and scientific (including by reference to statistical norms). Common hybrid views argue that the concept of mental disorder is objective but a “fuzzy prototype” that can never be precisely defined, or alternatively that it inevitably involves a mix of scientific facts and subjective value judgments.

One remarkable example of psychiatric diagnosis being used to reinforce cultural bias and oppress dissidence is the diagnosis of drapetomania. In the US prior to the American Civil War, physicians such as Samuel A. Cartwright diagnosed some slaves with drapetomania, a mental illness in which the slave possessed an irrational desire for freedom and a tendency to try to escape. By classifying such a dissident mental trait as abnormal and a disease, psychiatry promoted cultural bias about normality, abnormality, health, and unhealth. This example indicates the probability for not only cultural bias but also confirmation bias and bias blind spot in psychiatric diagnosis and psychiatric beliefs.

It has been argued by philosophers like Foucault that characterizations of “mental illness” are indeterminate and reflect the hierarchical structures of the societies from which they emerge rather than any precisely defined qualities that distinguish a “healthy” mind from a “sick” one. Furthermore, if a tendency toward self-harm is taken as an elementary symptom of mental illness, then humans, as a species, are arguably insane in that they have tended throughout recorded history to destroy their own environments, to make war with one another, etc.

Psychiatric Labelling

Mental disorders were first included in the sixth revision of the International Classification of Diseases (ICD-6) in 1949. Three years later, the American Psychiatric Association created its own classification system, DSM-I. The definitions of most psychiatric diagnoses consist of combinations of phenomenological criteria, such as symptoms and signs and their course over time. Expert committees combined them in variable ways into categories of mental disorders, defined and redefined them again and again over the last half century.

The majority of these diagnostic categories are called “disorders” and are not validated by biological criteria, as most medical diseases are; although they purport to represent medical diseases and take the form of medical diagnoses. These diagnostic categories are actually embedded in top-down classifications, similar to the early botanic classifications of plants in the 17th and 18th centuries, when experts decided a priori about which classification criterion to use, for instance, whether the shape of leaves or fruiting bodies were the main criterion for classifying plants. Since the era of Kraepelin, psychiatrists have been trying to differentiate mental disorders by using clinical interviews.

Experiments Admitting “Healthy” Individuals into Psychiatric Care

In 1972, psychologist David Rosenhan published the Rosenhan experiment, a study questioning the validity of psychiatric diagnoses. The study arranged for eight individuals with no history of psychopathology to attempt admission into psychiatric hospitals. The individuals included a graduate student, psychologists, an artist, a housewife, and two physicians, including one psychiatrist. All eight individuals were admitted with a diagnosis of schizophrenia or bipolar disorder. Psychiatrists then attempted to treat the individuals using psychiatric medication. All eight were discharged within 7 to 52 days. In a later part of the study, psychiatric staff were warned that pseudo-patients might be sent to their institutions, but none were actually sent. Nevertheless, a total of 83 patients out of 193 were believed by at least one staff member to be actors. The study concluded that individuals without mental disorders were indistinguishable from those suffering from mental disorders.

Critics such as Robert Spitzer placed doubt on the validity and credibility of the study, but did concede that the consistency of psychiatric diagnoses needed improvement. It is now realised that the psychiatric diagnostic criteria are not perfect. To further refine psychiatric diagnosis, according to Tadafumi Kato, the only way is to create a new classification of diseases based on the neurobiological features of each mental disorder. On the other hand, according to Heinz Katsching, neurologists are advising psychiatrists just to replace the term “mental illness” by “brain illness.”

There are recognised problems regarding the diagnostic reliability and validity of mainstream psychiatric diagnoses, both in ideal and controlled circumstances and even more so in routine clinical practice (McGorry et al.. 1995). Criteria in the principal diagnostic manuals, the DSM and ICD, are inconsistent. Some psychiatrists who criticise their own profession say that comorbidity, when an individual meets criteria for two or more disorders, is the rule rather than the exception. There is much overlap and vaguely defined or changeable boundaries between what psychiatrists claim are distinct illness states.

There are also problems with using standard diagnostic criteria in different countries, cultures, genders or ethnic groups. Critics often allege that Westernised, white, male-dominated psychiatric practices and diagnoses disadvantage and misunderstand those from other groups. For example, several studies have shown that African Americans are more often diagnosed with schizophrenia than Caucasians, and men more than women. Some within the anti-psychiatry movement are critical of the use of diagnosis as it conforms with the biomedical model.

Tool of Social Control

According to Franco Basaglia, Giorgio Antonucci, Bruce E. Levine and Edmund Schönenberger whose approach pointed out the role of psychiatric institutions in the control and medicalisation of deviant behaviours and social problems, psychiatry is used as the provider of scientific support for social control to the existing establishment, and the ensuing standards of deviance and normality brought about repressive views of discrete social groups. According to Mike Fitzpatrick, resistance to medicalisation was a common theme of the gay liberation, anti-psychiatry, and feminist movements of the 1970s, but now there is actually no resistance to the advance of government intrusion in lifestyle if it is thought to be justified in terms of public health.

In the opinion of Mike Fitzpatrick, the pressure for medicalisation also comes from society itself. As one example, Fitzpatrick claims that feminists who once opposed state intervention as oppressive and patriarchal, now demand more coercive and intrusive measures to deal with child abuse and domestic violence. According to Richard Gosden, the use of psychiatry as a tool of social control is becoming obvious in preventive medicine programmes for various mental diseases. These programmes are intended to identify children and young people with divergent behavioural patterns and thinking and send them to treatment before their supposed mental diseases develop. Clinical guidelines for best practice in Australia include the risk factors and signs which can be used to detect young people who are in need of prophylactic drug treatment to prevent the development of schizophrenia and other psychotic conditions.

Psychiatry and the Pharmaceutical Industry

Critics of psychiatry commonly express a concern that the path of diagnosis and treatment in contemporary society is primarily or overwhelmingly shaped by profit prerogatives, echoing a common criticism of general medical practice in the United States, where many of the largest psychopharmaceutical producers are based.

Psychiatric research has demonstrated varying degrees of efficacy for improving or managing a number of mental health disorders through either medications, psychotherapy, or a combination of the two. Typical psychiatric medications include stimulants, antidepressants, anxiolytics, and antipsychotics (neuroleptics).

On the other hand, organisations such as MindFreedom International and World Network of Users and Survivors of Psychiatry maintain that psychiatrists exaggerate the evidence of medication and minimize the evidence of adverse drug reaction. They and other activists believe individuals are not given balanced information, and that current psychiatric medications do not appear to be specific to particular disorders in the way mainstream psychiatry asserts; and psychiatric drugs not only fail to correct measurable chemical imbalances in the brain, but rather induce undesirable side effects. For example, though children on Ritalin and other psycho-stimulants become more obedient to parents and teachers, critics have noted that they can also develop abnormal movements such as tics, spasms and other involuntary movements. This has not been shown to be directly related to the therapeutic use of stimulants, but to neuroleptics. The diagnosis of attention deficit hyperactivity disorder on the basis of inattention to compulsory schooling also raises critics’ concerns regarding the use of psychoactive drugs as a means of unjust social control of children.

The influence of pharmaceutical companies is another major issue for the anti-psychiatry movement. As many critics from within and outside of psychiatry have argued, there are many financial and professional links between psychiatry, regulators, and pharmaceutical companies. Drug companies routinely fund much of the research conducted by psychiatrists, advertise medication in psychiatric journals and conferences, fund psychiatric and healthcare organisations and health promotion campaigns, and send representatives to lobby general physicians and politicians. Peter Breggin, Sharkey, and other investigators of the psycho-pharmaceutical industry maintain that many psychiatrists are members, shareholders or special advisors to pharmaceutical or associated regulatory organisations.

There is evidence that research findings and the prescribing of drugs are influenced as a result. A United Kingdom cross-party parliamentary inquiry into the influence of the pharmaceutical industry in 2005 concludes: “The influence of the pharmaceutical industry is such that it dominates clinical practice” and that there are serious regulatory failings resulting in “the unsafe use of drugs; and the increasing medicalisation of society”. The campaign organisation No Free Lunch details the prevalent acceptance by medical professionals of free gifts from pharmaceutical companies and the effect on psychiatric practice. The ghostwriting of articles by pharmaceutical company officials, which are then presented by esteemed psychiatrists, has also been highlighted. Systematic reviews have found that trials of psychiatric drugs that are conducted with pharmaceutical funding are several times more likely to report positive findings than studies without such funding.

The number of psychiatric drug prescriptions have been increasing at an extremely high rate since the 1950s and show no sign of abating. In the United States antidepressants and tranquilisers are now the top selling class of prescription drugs, and neuroleptics and other psychiatric drugs also rank near the top, all with expanding sales. As a solution to the apparent conflict of interests, critics propose legislation to separate the pharmaceutical industry from the psychiatric profession.

John Read and Bruce E. Levine have advanced the idea of socioeconomic status as a significant factor in the development and prevention of mental disorders such as schizophrenia and have noted the reach of pharmaceutical companies through industry sponsored websites as promoting a more biological approach to mental disorders, rather than a comprehensive biological, psychological and social model.

Electroconvulsive Therapy

Psychiatrists may advocate psychiatric drugs, psychotherapy or more controversial interventions such as electroshock or psychosurgery to treat mental illness. Electroconvulsive therapy (ECT) is administered worldwide typically for severe mental disorders. Across the globe it has been estimated that approximately 1 million patients receive ECT per year. Exact numbers of how many persons per year have ECT in the United States are unknown due to the variability of settings and treatment. Researchers’ estimates generally range from 100,000 to 200,000 persons per year.

Some persons receiving ECT die during the procedure (ECT is performed under a general anaesthetic, which always carries a risk). Leonard Roy Frank writes that estimates of ECT-related death rates vary widely.

  • The lower estimates include:
    • 2-4 in 100,000 (from Kramer’s 1994 study of 28,437 patients);
    • 1 in 10,000 (Boodman’s first entry in 1996);
    • 1 in 1,000 (Impastato’s first entry in 1957); and
    • 1 in 200, among the elderly, over 60 (Impastato’s in 1957).
  • Higher estimates include:
    • 1 in 102 (Martin’s entry in 1949);
    • 1 in 95 (Boodman’s first entry in 1996);
    • 1 in 92 (Freeman and Kendell’s entry in 1976);
    • 1 in 89 (Sagebiel’s in 1961);
    • 1 in 69 (Gralnick’s in 1946);
    • 1 in 63, among a group undergoing intensive ECT (Perry’s in 1963–1979);
    • 1 in 38 (Ehrenberg’s in 1955);
    • 1 in 30 (Kurland’s in 1959);
    • 1 in 9, among a group undergoing intensive ECT (Weil’s in 1949); and
    • 1 in 4, among the very elderly, over 80 (Kroessler and Fogel’s in 1974-1986).

Political Abuse of Psychiatry

Psychiatrists around the world have been involved in the suppression of individual rights by states in which the definitions of mental disease have been expanded to include political disobedience. Nowadays, in many countries, political prisoners are sometimes confined and abused in mental institutions. Psychiatry possesses a built-in capacity for abuse which is greater than in other areas of medicine. The diagnosis of mental disease can serve as proxy for the designation of social dissidents, allowing the state to hold persons against their will and to insist upon therapies that work in favour of ideological conformity and in the broader interests of society. In a monolithic state, psychiatry can be used to bypass standard legal procedures for establishing guilt or innocence and allow political incarceration without the ordinary odium attaching to such political trials.

Under the Nazi regime in the 1940s, the “duty to care” was violated on an enormous scale. In Germany alone 300,000 individuals that had been deemed mentally ill, work-shy or feeble-minded were sterilized. An additional 200,000 were euthanised. These practices continued in territories occupied by the Nazis further afield (mainly in eastern Europe), affecting thousands more. From the 1960s up to 1986, political abuse of psychiatry was reported to be systematic in the Soviet Union, and to surface on occasion in other Eastern European countries such as Romania, Hungary, Czechoslovakia, and Yugoslavia, as well as in Western European countries, such as Italy. An example of the use of psychiatry in the political field is the “case Sabattini”, described by Giorgio Antonucci in his book Il pregiudizio psichiatrico. A “mental health genocide” reminiscent of the Nazi aberrations has been located in the history of South African oppression during the apartheid era. A continued misappropriation of the discipline was later attributed to the People’s Republic of China.

K. Fulford, A. Smirnov, and E. Snow state: “An important vulnerability factor, therefore, for the abuse of psychiatry, is the subjective nature of the observations on which psychiatric diagnosis currently depends.” In an article published in 1994 by the Journal of Medical Ethics, American psychiatrist Thomas Szasz stated that “the classification by slave owners and slave traders of certain individuals as Negroes was scientific, in the sense that whites were rarely classified as blacks. But that did not prevent the ‘abuse’ of such racial classification, because (what we call) its abuse was, in fact, its use.” Szasz argued that the spectacle of the Western psychiatrists loudly condemning Soviet colleagues for their abuse of professional standards was largely an exercise in hypocrisy. Szasz states that K. Fulford, A. Smirnov, and E. Snow, who correctly emphasize the value-laden nature of psychiatric diagnoses and the subjective character of psychiatric classifications, fail to accept the role of psychiatric power. He stated that psychiatric abuse, such as people usually associated with practices in the former USSR, was connected not with the misuse of psychiatric diagnoses, but with the political power built into the social role of the psychiatrist in democratic and totalitarian societies alike. Musicologists, drama critics, art historians, and many other scholars also create their own subjective classifications; however, lacking state-legitimated power over persons, their classifications do not lead to anyone’s being deprived of property, liberty, or life. For instance, a plastic surgeon’s classification of beauty is subjective, but the plastic surgeon cannot treat his or her patient without the patient’s consent, so there cannot be any political abuse of plastic surgery.

The bedrock of political medicine is coercion masquerading as medical treatment. In this process, physicians diagnose a disapproved condition as an “illness” and declare the intervention they impose on the victim a “treatment,” and legislators and judges legitimate these categorisations. In the same way, physician-eugenicists advocated killing certain disabled or ill persons as a form of treatment for both society and patient long before the Nazis came to power.

From the commencement of his political career, Hitler put his struggle against “enemies of the state” in medical rhetoric. In 1934, addressing the Reichstag, he declared, “I gave the order… to burn out down to the raw flesh the ulcers of our internal well-poisoning.” The entire German nation and its National Socialist politicians learned to think and speak in such terms. Werner Best, Reinhard Heydrich’s deputy, stated that the task of the police was “to root out all symptoms of disease and germs of destruction that threatened the political health of the nation… [In addition to Jews,] most [of the germs] were weak, unpopular and marginalized groups, such as gypsies, homosexuals, beggars, ‘antisocials’, ‘work-shy’, and ‘habitual criminals’.”

In spite of all the evidence, people ignore or underappreciate the political implications of the pseudotherapeutic character of Nazism and of the use of medical metaphors in modern democracies. Dismissed as an “abuse of psychiatry”, this practice is a controversial subject not because the story makes psychiatrists in Nazi Germany look bad, but because it highlights the dramatic similarities between pharmacratic controls in Germany under Nazism and those that have emerged in the US under the free market economy.

The Swiss lawyer Edmund Schönenberger claims that the strongholds of psychiatry are instruments of domination and have nothing to do with care, the law, or justice.

“Therapeutic State”

The “therapeutic state” is a phrase coined by Szasz in 1963. The collaboration between psychiatry and government leads to what Szasz calls the “therapeutic state”, a system in which disapproved actions, thoughts, and emotions are repressed (“cured”) through pseudomedical interventions. Thus suicide, unconventional religious beliefs, racial bigotry, unhappiness, anxiety, shyness, sexual promiscuity, shoplifting, gambling, overeating, smoking, and illegal drug use are all considered symptoms or illnesses that need to be cured. When faced with demands for measures to curtail smoking in public, binge-drinking, gambling or obesity, ministers say that “we must guard against charges of nanny statism”. The “nanny state” has turned into the “therapeutic state” where nanny has given way to counsellor. Nanny just told people what to do; counsellors also tell them what to think and what to feel. The “nanny state” was punitive, austere, and authoritarian, the therapeutic state is touchy-feely, supportive – and even more authoritarian. According to Szasz, “the therapeutic state swallows up everything human on the seemingly rational ground that nothing falls outside the province of health and medicine, just as the theological state had swallowed up everything human on the perfectly rational ground that nothing falls outside the province of God and religion”.

Faced with the problem of “madness”, Western individualism proved to be ill-prepared to defend the rights of the individual: modern man has no more right to be a madman than medieval man had a right to be a heretic because if once people agree that they have identified the one true God, or Good, it brings about that they have to guard members and non-members of the group from the temptation to worship false gods or goods. A secularisation of God and the medicalisation of good resulted in the post-Enlightenment version of this view: once people agree that they have identified the one true reason, it brings about that they have to guard against the temptation to worship unreason – that is, madness.

Civil libertarians warn that the marriage of the State with psychiatry could have catastrophic consequences for civilisation. In the same vein as the separation of church and state, Szasz believes that a solid wall must exist between psychiatry and the State.

“Total Institution”

In his book Asylums, Erving Goffman coined the term ‘total institution’ for mental hospitals and similar places which took over and confined a person’s whole life. Goffman placed psychiatric hospitals in the same category as concentration camps, prisons, military organisations, orphanages, and monasteries. In Asylums Goffman describes how the institutionalisation process socialises people into the role of a good patient, someone ‘dull, harmless and inconspicuous’; it in turn reinforces notions of chronicity in severe mental illness.

Law

While the insanity defence is the subject of controversy as a viable excuse for wrongdoing, Szasz and other critics contend that being committed in a psychiatric hospital can be worse than criminal imprisonment, since it involves the risk of compulsory medication with neuroleptics or the use of electroshock treatment. Moreover, while a criminal imprisonment has a predetermined and known time of duration, patients are typically committed to psychiatric hospitals for indefinite durations, an unjust and arguably outrageous imposition of fundamental uncertainty. It has been argued that such uncertainty risks aggravating mental instability, and that it substantially encourages a lapse into hopelessness and acceptance that precludes recovery.

Involuntary Hospitalisation

Critics see the use of legally sanctioned force in involuntary commitment as a violation of the fundamental principles of free or open societies. The political philosopher John Stuart Mill and others have argued that society has no right to use coercion to subdue an individual as long as he or she does not harm others. Mentally ill people are essentially no more prone to violence than sane individuals, despite Hollywood and other media portrayals to the contrary. The growing practice, in the United Kingdom and elsewhere, of Care in the Community was instituted partly in response to such concerns. Alternatives to involuntary hospitalisation include the development of non-medical crisis care in the community.

In the case of people suffering from severe psychotic crises, the American Soteria project used to provide what was argued to be a more humane and compassionate alternative to coercive psychiatry. The Soteria houses closed in 1983 in the United States due to lack of financial support. However, similar establishments are presently flourishing in Europe, especially in Sweden and other North European countries.

The physician Giorgio Antonucci, during his activity as a director of the Ospedale Psichiatrico Osservanza of Imola, refused any form of coercion and any violation of the fundamental principles of freedom, questioning the basis of psychiatry itself.

Psychiatry as Pseudoscience and Failed Enterprise

Many of the above issues lead to the claim that psychiatry is a pseudoscience. According to some philosophers of science, for a theory to qualify as science it needs to exhibit the following characteristics:

  • Parsimony, as straightforward as the phenomena to be explained allow (see Occam’s razor);
  • Empirically testable and falsifiable (see Falsifiability);
  • Changeable, i.e. if necessary, changes may be made to the theory as new data are discovered;
  • Progressive, encompasses previous successful descriptions and explains and adds more; and
  • Provisional, i.e. tentative; the theory does not attempt to assert that it is a final description or explanation.

Psychiatrist Colin A. Ross and Alvin Pam maintain that biopsychiatry does not qualify as a science on many counts.

Psychiatric researchers have been criticised on the basis of the replication crisis and textbook errors. Questionable research practices are known to bias key sources of evidence.

Stuart A. Kirk has argued that psychiatry is a failed enterprise, as mental illness has grown, not shrunk, with about 20% of American adults diagnosable as mentally ill in 2013.

According to a 2014 meta-analysis, psychiatric treatment is no less effective for psychiatric illnesses in terms of treatment effects than treatments by practitioners of other medical specialties for physical health conditions. The analysis found that the effect sizes for psychiatric interventions are, on average, on par with other fields of medicine.

Diverse Paths

Szasz has since (2008) re-emphasized his disdain for the term anti-psychiatry, arguing that its legacy has simply been a “catchall term used to delegitimise and dismiss critics of psychiatric fraud and force by labelling them ‘antipsychiatrists'”. He points out that the term originated in a meeting of four psychiatrists (Cooper, Laing, Berke and Redler) who never defined it yet “counter-label[led] their discipline as anti-psychiatry”, and that he considers Laing most responsible for popularising it despite also personally distancing himself. Szasz describes the deceased (1989) Laing in vitriolic terms, accusing him of being irresponsible and equivocal on psychiatric diagnosis and use of force, and detailing his past “public behaviour” as “a fit subject for moral judgment” which he gives as “a bad person and a fraud as a professional”.

Daniel Burston, however, has argued that overall the published works of Szasz and Laing demonstrate far more points of convergence and intellectual kinship than Szasz admits, despite the divergence on a number of issues related to Szasz being a libertarian and Laing an existentialist; that Szasz employs a good deal of exaggeration and distortion in his criticism of Laing’s personal character, and unfairly uses Laing’s personal failings and family woes to discredit his work and ideas; and that Szasz’s “clear-cut, crystalline ethical principles are designed to spare us the agonising and often inconclusive reflections that many clinicians face frequently in the course of their work”. Szasz has indicated that his own views came from libertarian politics held since his teens, rather than through experience in psychiatry; that in his “rare” contacts with involuntary mental patients in the past he either sought to discharge them (if they were not charged with a crime) or “assisted the prosecution in securing [their] conviction” (if they were charged with a crime and appeared to be prima facie guilty); that he is not opposed to consensual psychiatry and “does not interfere with the practice of the conventional psychiatrist”, and that he provided “listening-and-talking (“psychotherapy”)” for voluntary fee-paying clients from 1948 until 1996, a practice he characterises as non-medical and not associated with his being a psychoanalytically trained psychiatrist.

The gay rights or gay liberation movement is often thought to have been part of anti-psychiatry in its efforts to challenge oppression and stigma and, specifically, to get homosexuality removed from the American Psychiatric Association’s (APA) Diagnostic and Statistical Manual of Mental Disorders. However, a psychiatric member of APA’s Gay, Lesbian, and Bisexual Issues Committee has recently sought to distance the two, arguing that they were separate in the early 70s protests at APA conventions and that APA’s decision to remove homosexuality was scientific and happened to coincide with the political pressure. Reviewers have responded, however, that the founders and movements were closely aligned; that they shared core texts, proponents and slogans; and that others have stated that, for example, the gay liberation critique was “made possible by (and indeed often explicitly grounded in) traditions of antipsychiatry”.

In the clinical setting, the two strands of anti-psychiatry – criticism of psychiatric knowledge and reform of its practices – were never entirely distinct. In addition, in a sense, anti-psychiatry was not so much a demand for the end of psychiatry, as it was an often self-directed demand for psychiatrists and allied professionals to question their own judgements, assumptions and practices. In some cases, the suspicion of non-psychiatric medical professionals towards the validity of psychiatry was described as anti-psychiatry, as well the criticism of “hard-headed” psychiatrists towards “soft-headed” psychiatrists. Most leading figures of anti-psychiatry were themselves psychiatrists, and equivocated over whether they were really “against psychiatry”, or parts thereof. Outside the field of psychiatry, however – e.g. for activists and non-medical mental health professionals such as social workers and psychologists – ‘anti-psychiatry’ tended to mean something more radical. The ambiguous term “anti-psychiatry” came to be associated with these more radical trends, but there was debate over whether it was a new phenomenon, whom it best described, and whether it constituted a genuinely singular movement. In order to avoid any ambiguity intrinsic to the term anti-psychiatry, a current of thought that can be defined as critique of the basis of psychiatry, radical and unambiguous, aims for the complete elimination of psychiatry. The main representative of the critique of the basis of psychiatry is an Italian physician, Giorgio Antonucci, the founder of the non-psychiatric approach to psychological suffering, who posited that the “essence of psychiatry lies in an ideology of discrimination”.

In the 1990s, a tendency was noted among psychiatrists to characterize and to regard the anti-psychiatric movement as part of the past, and to view its ideological history as flirtation with the polemics of radical politics at the expense of scientific thought and enquiry. It was also argued, however, that the movement contributed towards generating demand for grassroots involvement in guidelines and advocacy groups, and to the shift from large mental institutions to community services. Additionally, community centres have tended in practice to distance themselves from the psychiatric/medical model and have continued to see themselves as representing a culture of resistance or opposition to psychiatry’s authority. Overall, while antipsychiatry as a movement may have become an anachronism by this period and was no longer led by eminent psychiatrists, it has been argued that it became incorporated into the mainstream practice of mental health disciplines. On the other hand, mainstream psychiatry became more biomedical, increasing the gap between professionals.

Henry Nasrallah claims that while he believes anti-psychiatry consists of many historical exaggerations based on events and primitive conditions from a century ago, “antipsychiatry helps keep us honest and rigorous about what we do, motivating us to relentlessly seek better diagnostic models and treatment paradigms. Psychiatry is far more scientific today than it was a century ago, but misperceptions about psychiatry continue to be driven by abuses of the past. The best antidote for antipsychiatry allegations is a combination of personal integrity, scientific progress, and sound evidence-based clinical care”.

A criticism was made in the 1990s that three decades of anti-psychiatry had produced a large literature critical of psychiatry, but little discussion of the deteriorating situation of the mentally troubled in American society. Anti-psychiatry crusades have thus been charged with failing to put suffering individuals first, and therefore being similarly guilty of what they blame psychiatrists for. The rise of anti-psychiatry in Italy was described by one observer as simply “a transfer of psychiatric control from those with medical knowledge to those who possessed socio-political power”.

Critics of this view, however, from an anti-psychiatry perspective, are quick to point to the industrial aspects of psychiatric treatment itself as a primary causal factor in this situation that is described as “deteriorating”. The numbers of people labelled “mentally ill”, and in treatment, together with the severity of their conditions, have been going up primarily due to the direct efforts of the mental health movement, and mental health professionals, including psychiatrists, and not their detractors. Envisioning “mental health treatment” as violence prevention has been a big part of the problem, especially as you are dealing with a population that is not significantly more violent than any other group and, in fact, are less so than many.

On 07 October 2016, the Ontario Institute for Studies in Education (OISE) at the University of Toronto announced that they had established a scholarship for students doing theses in the area of antipsychiatry. Called “The Bonnie Burstow Scholarship in Antipsychiatry,” it is to be awarded annually to an OISE thesis student. An unprecedented step, the scholarship should further the cause of freedom of thought and the exchange of ideas in academia. The scholarship is named in honour of Bonnie Burstow, a faculty member at the University of Toronto, a radical feminist, and an antipsychiatry activist. She is also the author of Psychiatry and the Business of Madness (2015).

Some components of antipsychiatric theory have in recent decades been reformulated into a critique of “corporate psychiatry”, heavily influenced by the pharmaceutical industry. A recent editorial about this was published in the British Journal of Psychiatry by Moncrieff, arguing that modern psychiatry has become a handmaiden to conservative political commitments. David Healy is a psychiatrist and professor in psychological medicine at Cardiff University School of Medicine, Wales. He has a special interest in the influence of the pharmaceutical industry on medicine and academia.

In the meantime, members of the psychiatric consumer/survivor movement continued to campaign for reform, empowerment and alternatives, with an increasingly diverse representation of views. Groups often have been opposed and undermined, especially when they proclaim to be, or when they are labelled as being, “anti-psychiatry”. However, as of the 1990s, more than 60% of ex-patient groups reportedly support anti-psychiatry beliefs and consider themselves to be “psychiatric survivors”. Although anti-psychiatry is often attributed to a few famous figures in psychiatry or academia, it has been pointed out that consumer/survivor/ex-patient individuals and groups preceded it, drove it and carried on through it.

Criticism

A schism exists among those critical of conventional psychiatry between radical abolitionists and more moderate reformists. Laing, Cooper and others associated with the initial anti-psychiatry movement stopped short of actually advocating for the abolition of coercive psychiatry. Thomas Szasz, from near the beginning of his career, crusaded for the abolition of forced psychiatry. Today, believing that coercive psychiatry marginalises and oppresses people with its harmful, controlling, and abusive practices, many who identify as anti-psychiatry activists are proponents of the complete abolition of non-consensual and coercive psychiatry.

Criticism of antipsychiatry from within psychiatry itself object to the underlying principle that psychiatry is by definition harmful. Most psychiatrists accept that issues exist that need addressing, but that the abolition of psychiatry is harmful. Nimesh Desai concludes: “To be a believer and a practitioner of multidisciplinary mental health, it is not necessary to reject the medical model as one of the basics of psychiatry.” and admits “Some of the challenges and dangers to psychiatry are not so much from the avowed antipsychiatrists, but from the misplaced and misguided individuals and groups in related fields.”

Does VRET & ARET Work as a Treatment for PTSD?

Research Paper Title

Efficacy of immersive PTSD treatments: A systematic review of virtual and augmented reality exposure therapy and a meta-analysis of virtual reality exposure therapy.

Background

Virtual reality exposure therapy (VRET) and augmented reality exposure therapy (ARET) are digitally assisted psychotherapies that potentially enhance posttraumatic stress disorder (PTSD) treatment by increasing a patient’s sense of presence during exposure therapy.

This study aimed to systematically review current evidence regarding the efficacy of VRET and ARET as PTSD treatment.

Methods

A systematic electronic database search, a systematic quality assessment and two meta-analyses were conducted in accordance with PRISMA guidelines.

Results

Eleven studies on the efficacy of VRET for PTSD (n = 438) were found, but no studies on the efficacy of ARET. The majority of VRET studies were of a low quality and had heterogeneous results. Meta-analyses showed VRET outperformed waitlist control (standardised mean difference -0.64 (95% CI -1.05 to -0.22)) while no significant difference was found between VRET and active treatment conditions (standardised mean difference -0.25 (95% CI -0.77 to 0.27)).

Conclusions

VRET was superior to waitlist control groups and as effective as other psychotherapies. However, the results showed considerable heterogeneity due to the low number of studies and variety of VRET methods. VRET may be an effective alternative to current treatments and shows promise for the treatment of PTSD patients that have not responded to previous treatment.

Future research should focus on high quality RCTs, including information on side effects and adverse events, with sufficient numbers of participants.

This study recognises a research gap regarding the efficacy of ARET, while it may have potential for PTSD treatment.

Reference

Eshuis, L.V., van Gelderen, M.J., van Zuidan, M., Nijdam, M.J., Vermetten, E., Olff, M. & Bakker, A. (2020) Efficacy of immersive PTSD treatments: A systematic review of virtual and augmented reality exposure therapy and a meta-analysis of virtual reality exposure therapy. Journal of Psychiatric Research. doi: 10.1016/j.jpsychires.2020.11.030. Online ahead of print.

Are Treatments for Common Mental Disorders also Effective for Functional Symptoms & Disorder?

Research Paper Title

Are treatments for common mental disorders also effective for functional symptoms and disorder?

Background

To consider whether the many types of treatments for mental disorders – both those specifically targeting illness mechanisms and nonspecific elements – are also effective in treating functional symptoms and syndromes. The paper discusses the need for well-organised care that emphasizes early treatment and recognition of more complex problems in primary and secondary medical care.

Methods

Evidence from a wide range of research and clinical experience is used to identify and illustrate general themes.

Results

Despite a limited evidence base, it is clear that both specific and nonspecific interventions that are effective with mental disorders are also effective in treating functional complaints. They are also helpful in the management of maladaptive reactions to physical disorders. Delivery is most effective as stepped care.

Conclusions

There is a particular need for more evidence on the effectiveness of the nonspecific elements of treatment and of their most appropriate delivery by non-specialists in general medical settings.

Experience with a variety of treatment methods will enhance our understanding of psychological and other etiological variables and thereby influence the development of improved definitions in Diagnostic and Statistical Manual of Mental Disorders-5(th) Edition.

It is argued that a main focus of review of somatoform disorder should be the resolution of conceptual problems.

Reference

Mayou, R. (2020) Are treatments for common mental disorders also effective for functional symptoms and disorder? Psychosomatic Medicine. 69(9), pp.876-880. doi: 10.1097/PSY.0b013e31815b00a6.

Book: Mental: Everything You Never Knew You Needed to Know about Mental Health

Book Title:

Mental: Everything You Never Knew You Needed to Know about Mental Health.

Author(s): Dr Steve Ellen and Catherine Deveny.

Year: 2018.

Edition: First (1st).

Publisher: Anima.

Type(s): Hardcover, Paperback, Audiobook, and Kindle.

Synopsis:

How do we define mental illness? What does a diagnosis mean? What should you ask your doctor before you begin treatment? Are there alternatives to medication? What does the research show actually works?

Practitioner and professor of psychiatry Dr Steve Ellen and popular comedian Catherine Deveny combine forces to demystify the world of mental health. Sharing their personal experiences of mental illness and an insider perspective on psychiatry, they unpack the current knowledge about conditions and treatments coveing everything from depression and anxiety to schizophrenia, personality disorders and substance abuse.

Whether you have a mental illness or support someone who does, Mental offers clear practical help, empowering you with an arsenal of tips and techniques to help build your resilience.

Creativity & its Role in the Treatment & Recovery of those with Mental Disorders

Research Paper Title

Creativity, mental disorders and their treatment: recovery-oriented psychopharmacotherapy.

Background

This paper discusses interrelations between creativity, mental disorders and their treatment.

The psychology of creativity is very important for successful psychopharmacotherapy, but our knowledge about creativity is still insufficient.

Even that which is known is not within the armamentarium of most practicing psychiatrists.

  • In the first part of this article creativity and possible associations between creativity, mental health, and well-being are described.
  • The second part deals with the intriguing relationship between creativity and mental disorders.
  • The third part emphasizes the role of creativity in the treatment of mental disorders.

This paper ends by underlining the importance of a creativity-enhancing oriented, and personal recovery-focused psychopharmacotherapy in helping psychiatric patients achieve fulfilled and purposeful lives.

Reference

Jakovljevic, M. (2020) Creativity, mental disorders and their treatment: recovery-oriented psychopharmacotherapy. Psychiatria Danubina. 25(3), pp.311-315.

What are the Incidence Rates of Treated Mental Disorders in Childhood & Adolescence?

Research Paper Title

Incidence Rates of Treated Mental Disorders in Childhood and Adolescence in a Complete Nationwide Birth Cohort.

Background

To investigate incidences, cumulative incidence rates, and risk factors of diagnosed mental disorders in a complete nationwide birth cohort across the entire period of childhood and adolescence.

Methods

Based on nationwide Danish registries, the entire cohort of all children born in 1995 was followed up to 31 December 2013. Data for children who migrated during the period were censored in the time analyses, and death before age 18 years was considered a competing risk. Incidence rates and cumulative incidence rates for any first-time-diagnosed mental disorder and 10 major categories of mental disorders according to ICD-10 criteria were calculated for 68,982 individuals. In addition, the effects of age, sex, and further child- and family-related risk factors on mental disorders were analysed.

Results

The incidences of any mental disorder, substance use disorders, depression, and anxiety disorders showed an increase in adolescence, whereas those for autism spectrum disorders, attention-deficit/hyperactivity disorder, conduct disorder, and tic disorder increased during childhood and decreased thereafter. Males had higher incidence rates of any mental disorders, substance use disorders, autism spectrum disorders, ADHD, conduct disorder, and tic disorder. Females had higher risks for depressive, anxiety, obsessive-compulsive, and eating disorders. Several other risk and protective factors for any mental disorder were identified. The cumulative incidence rate at age 18 years amounted to 11.02% for any mental disorder.

Conclusions

These findings provide the most comprehensive estimates of the development, incidence rates, and contributing risk factors of registered mental disorders for the entire period of childhood and adolescence that have been calculated so far.

Reference

Steinhausen, H-C. & Jakobsen, H. (2020) Incidence Rates of Treated Mental Disorders in Childhood and Adolescence in a Complete Nationwide Birth Cohort. The Journal of Clinical Psychiatry. 80(3):17m12012. doi: 10.4088/JCP.17m12012.

Book: Clean – Overcoming Addiction And Ending America’s Greatest Tragedy

Book Title:

Clean – Overcoming Addiction And Ending America’s Greatest Tragedy.

Author(s): David Sheff.

Year: 2014.

Edition: First (1st).

Publisher: Houghton Mifflin Harcourt.

Type(s): hardcover, Paperback, and Audiobook.

Synopsis:

Addiction is a preventable, treatable disease, not a moral failing.

As with other illnesses, the approaches most likely to work are based on science – not on faith, tradition, contrition, or wishful thinking. These facts are the foundation of Clean.

The existing addiction treatments, including Twelve Step programmes and rehabs, have helped some, but they have failed to help many more.

To discover why, David Sheff spent time with scores of scientists, doctors, counsellors, and addicts and their families, and explored the latest research in psychology, neuroscience, and medicine.

In Clean, he reveals how addiction really works, and how we can combat it.

Book: The ADHD Explosion

Book Title:

The ADHD Explosion: Myths, Medication, Money, and Today’s Push for Performance.

Author(s): Stephen P. Hinshaw and Richard M. Scheffler.

Year: 2014.

Edition: First (1st).

Publisher: Oxford University Press.

Type(s): Hardcover and Kindle.

Synopsis:

Attention-deficit/hyperactivity disorder (ADHD) is one of the most controversial and misunderstood medical conditions today.

With skyrocketing rates of diagnosis and medication treatment, it has generated a firestorm of controversy.

Alarming questions have been raised about ADHD in recent years:

  • Why are over 10% of children and adolescents in the US now diagnosed with ADHD, with projected rates quickly rising?
  • Why do over two-thirds of those diagnosed with ADHD receive medication?
  • In some southern states, why are boys diagnosed at rates of almost one in three?
  • What is causing the fast-rising diagnosis and medication of adults? Why are over a quarter of all college students using stimulants for academic performance?
  • What drives the current ADHD “tsunami” – is it parents, clinicians, schools, culture, the healthcare system, or Big Pharma? When will it end?
  • Can we trust the stories we read and hear about ADHD, even in major media outlets?

The ADHD Explosion and Today’s Push for Performance uniquely blends clinical wisdom, current science, new information on medical and school policy, and global trends to debunk myths and set the record straight.

Hinshaw and Scheffler describe the origins of ADHD and its huge costs to society; the science regarding causes as well as medication and behavioural treatment; and the major variation in diagnosis and treatment across the US, highlighting the key roles of educational policy and high-stakes testing. Dealing directly with stimulants as “smart pills,” they describe the epidemic of medicalisation, arguing that accurate diagnosis and well-monitored care could ease the staggering economic burden linked to ADHD.

In novel ways, they unravel the many poignant issues facing children, teachers, clinicians, and family members who contend with ADHD each day. The recommendations in this book can improve the quality of life for those touched by ADHD and potentially improve the productivity and safety of all society.